Volume 2 Issue 1
Abstracts from the AVAS 1st Annual Scientific Meeting
PAPERS
2. Microbial biofilms on intravascular catheters from paediatric patients
Dr. Li Zhang1, 5*, Ms. Nicole Marsh1, 2, Dr. Debbie Long1, 3, Prof. Ming Wei4, Prof. Mark Morrison5 and Prof. Claire M. Rickard1, 2
1AVATAR Group, Research Centre for Health Practice Innovation, Menzies Health Institute Queensland, Griffith University, QLD, Australia;
2Centre for Clinical Nursing, Royal Brisbane and Women’s Hospital, Herston, QLD, Australia;
3Paediatric Intensive Care Unit, Lady Cilento Children’s Hospital, QLD, Australia
4School of Medical Science, Menzies Health Institute Queensland, Griffith University, QLD, Australia;
5The University of Queensland Diamantina Institute, Translational Research Institute, Woolloongabba, QLD, Australia;
Abstract
Introduction: Microbial biofilm play important roles in intravascular catheter (IVC)-related infections, which are the most serious complications in children with IVCs, leading to increased hospitalization, intensive care admissions, extensive antibiotic treatment and mortality. A greater understanding of bacterial communities is needed to improve the management of infections.
Objectives: Twenty-four IVC samples (6 peripherally inserted central catheters, 8 central venous catheters and 10 arterial catheters) were collected from 24 paediatric patients aged 0 to 14 years old.
Methods: We describe here the systematic culture-independent evaluation of IVC bacteriology in IVC biofilms.
Results: Barcoded amplicon libraries produced from genes coding 16S rRNA and roll-plate culture methods were used to determine the microbial community composition of these samples.From a total of 1,043,406 high quality sequence reads, 8 microbial phyla and 136 diverse microbial genera were detected, separated into 12,224 operational taxonomic units. Three phyla (Actinobacteria, Firmicutes and Proteobacteria) predominante the microbial communities on the IVC surfaces, with Firmicutes representing nearly half of the OTUs found. Among the Firmicutes, Staphylococcus (15.0% of 16S rRNA reads), Streptococcus (9.6%) and Bacillus (6.1%) were most common.
Conclusions: Community composition did not appear to be affected by patients’ age, gender, antibiotic treatment or IVC type. Differences in IVC microbial biofilms were more likely associated with events arising from catheter dwell time, rather than the type of IVC used.
10. Vascular access device care: practices that will save lives, time & money
Professor Marie Cooke; Professor Claire Rickard; Amanda Ullman. Avatar Group, Griffith University, Queensland Australia.
Introduction: Vascular Access Device (VAD) complications and failure has a multifocal impact on the patient, family and healthcare system. It may require another painful and resource-intensive insertion procedure for a new VAD and can cause significant patient suffering, prolonged hospitalisation, and increase both healthcare costs and mortality. Interruption to prescribed treatment, including time- sensitive regimens of antibiotics, inotropic support and anti-cancer therapies can also result from VAD failure. Objectives: The aim was to synthesise knowledge about vascular access practices from the findings of primary studies to recommend to clinicians and policy makers steps to reduce VAD failure and complications. Methods: We used the case of a hospital with 450 acute care beds and demonstrated the impact if five practices with an evidence-base from the literature were actioned by clinicians in terms of lives, time and money. Results: Incorporating strategies in five VAD practices to reduce failure can result in major savings in health-care costs and improve patients’ satisfaction and experience. Conclusion: A consistent finding from the literature is that the transfer of research findings into clinical practice and policy can be problematic and slow. It has been argued that a good proportion of the care provided to patients is not in accordance with the evidence and in fact possibly harmful. Our review, identified, five simple evidence-based practices, which if consistently applied by clinicians, would save lives, time and money.
11. “To cut or not to cut...not such a simple question”: a comparison of paediatric peripherally inserted central catheter (picc) insertion techniques.
Mr Joel Mason, CNS2 Vascular Access, CRNI.
The Sydney Children’s Hospital, NSW, Australia.
Introduction: PICCs are essential devices used in paediatric patients requiring central intravenous access. Though not been formally examined in paediatrics, adult-based literature suggests that the practice of trimming PICC lines prior to insertion will reduce complications.
Objectives: To assess if trimming a paediatric PICC prior to insertion reduces the risk of line- associated complications during catheter dwell.
Method: A pilot cohort study was conducted at Sydney Children’s Hospital, reviewing all PICCs inserted by anaesthetists between 1/1/13-30/6/15. The exposure of trimming or not trimming paediatric PICCs prior to insertion was observed. Insertion and inpatient observations/outcome data was collected by the Vascular Access CNS2. A PICC was complicated if the device was removed due to one of 4 observed outcomes (migration, occlusion, extravasation and infection). Risk ratio and 95% CI were calculated.
Results: 383 paediatric PICCs (227 included) were inserted during the study period. 99 PICCs were trimmed, 128 left untrimmed. 29 complications were observed (5 trimmed, 25 untrimmed). Outcomes
trimmed:untrimmed as follows: Migration 1:4; Occlusions 2:13; Extravasation 1:4; Infection 0:4. RR=0.5 (95% CI 0.3, 0.998) was calculated for all trimmed PICCs. For individual outcomes RR<1 was calculated but 95% CI was observed as >1 in all instances.
Conclusion: Trimmed PICCs demonstrated a 50% risk reduction of complications. This is both clinically and statistically significant, as proportionally less complicated outcomes are observed in the trimmed PICC cohort. Statistical significance does not translate to the individual outcomes. A much larger cohort is required to determine the validity of these findings.
13. Early cannulation graft for reduce the central venous catheter: results of italian single center 4 years experience
Matteo Tozzi, Marco Franchin, Barbara Pasqualetti and Gabriele Piffaretti
University of Insubria
Introduction: This study evaluated 4 years ( from 2011 to 2015) of prosthetic vascular access (pVA) management in patients without native options for vascular access. Our experience is based on Acuseal graft (Acuseal® W.L Gore – Flagstaff; AZ - USA).
Objective: The present is a single center experience with retrospective analysis. We considered patients requiring vascular access with malfunctioning CVC (temporary or tunnelled cvc) that received pVA for early cannulation.
Methods: One-hundred patients (mean age 60±12 years; 64 male) were treated: 45 with CVC, 30 with a malfunctioning aVA, 25 without any vascular access requiring HD urgent.
Results: Graft implantation was technically successful in all cases and early cannulation within 24 hours was performed in all cases. Primary patency was 60.3% and secondary 85.3% at 46 months. In our operating protocol the CVCT or CVC are removed 12/24 h before the operating in case of malfunctioning or rececent bacteremia (N°36 – 80%) and 2.4 days of mean, after the surgery , in other cases (N° 9 – 20%). We removed all the CVC (N°45) without temporary solution.
Conclusion: In our experience, the use of acuseal graft for early cannulation has allowed us to reduce the number and the permanence of cvc; infact the early cannulation of the graft reduce the permanence in days of cvc ( range 1-4 mean 2.4 days) respect to standard ePTFE and it allows the removal of all infected or malfunctioning cvc before surgery.
this practice in our center allows to reduce the percentage of cvc from 22.6% (2011) to 12.9% (2014) . the use of this practice will lead to a reduction in the time of bacteremia and central venous stenosis.
14. The challenges and benefits of including paediatric population into trial research within a collaborative model.
Ms. Tricia Kleidon1-3, Ms. Amanda Ullman2,3, Ms.Victoria Gibson1,2, Ms.Julieta Woosley1,2 Ms. Anna Dean1,2 Ms.Julie Flynn,2,3 ,Dr. Zhang Li,2,3 Dr. Samantha Keogh,2,3, Professor Claire Rickard,2,3
1 CHQ HHS, South Brisbane, Queensland, Australia,
2 Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Griffith University, Kessels Rd, Nathan, QLD, Australia
3 NHMRC Centre of Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia.
Introduction: Paediatric patients are especially vulnerable to potential complications associated with vascular access (VA), due to their immature anatomy and immune response. However, there is limited quality evidence to inform VA practice, especially in paediatrics. The Alliance for Vascular Access Teaching and Research (AVATAR) group, undertakes rigorous research to identify gaps in VA knowledge and practice and evaluate innovative solutions; aiming to transform the development, delivery and experience of VA in healthcare.
Objectives:
1. Describe the processes, challenges and benefits of including paediatric patients in trials related to VA research
2. Outline the development of a collaborative partnership between clinicians and university researchers to establish a program of VA research in the paediatric population
Methods: A case study analysis reflecting on a recent pilot trials that included paediatric patients, evaluating the feasibility and impact of different VA flushing practice, dressing and securement methods.
Results: The analysis identified challenges associated with (1) recruitment, (2) clinical challenges with interventions in the paediatric setting, and (3) integrating trial process into standard practice. Strategies for managing these challenges included (1) extending timeline for recruitment, (2) modifying intervention arms, and (3) engaging local staff from the study inception and as research assistants.
Conclusions: Paediatric patients and practice have unique features, which must be taken into consideration when developing research protocols for intervention research.
16. Central venous access device securement and dressing effectiveness in paediatrics (cascade jnr): pilot study in peripherally inserted central catheters
Ms. Tricia Kleidon1-3 Ms. Amanda Ullman2,3, Ms.Victoria Gibson1,2, Dr.Brett Chaseling1, Dr.Jason Schoutrop,1 Ms. Julieta Woosley1,2,
Ms. Anna Dean1,2, Professor Claire Rickard,2,3
1 Lady Cilento Children’s Hospital, CHQ HHS, South Brisbane, Queensland, Australia,
2 Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Griffith University, Kessels Rd, Nathan, QLD, Australia
3 NHMRC Centre of Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia,
Introduction: Peripherally inserted central catheters (PICC’s) aim to provide reliable vascular access, however almost 30% of PICC’s fail before completion of treatment. PICC’s predominantly fail due to dislodgement, occlusion or infection (local or systemic) and failure is frequently attributed to inadequate securement and dressing of the device. Despite its ubiquity, quality research of PICC securement is scarce.
Objectives: To establish the feasibility of undertaking a full efficacy randomised control trial (RCT) examining the effectiveness of current and new technologies to secure PICC in paediatrics.
Methods: A single centre, parallel group, superiority pilot RCT of paediatric patients with PICC admitted to the Royal Children’s Hospital and Lady Cilento Children’s Hospital, Brisbane. Participants were randomised to receive PICC dressing and securement via:
1. Standard care: Bordered Polyurethane(BPU) Sutureless Securement Device (SSD) (BPU + SSD; StatLock®; Bard),
2. Tissue adhesive (TA; Histoacryl®; Ethicon & BPU)
3. Integrated dressing and securement product (IDS; SorbaView Shield®; Centurion)
Primary outcomes: Feasibility (including effect size estimates); Secondary outcomes: All cause PICC complication and failure; patient, family and staff satisfaction, skin damage and dressing performance.
Results: One hundred and one participants were recruited, feasibility criteria was achieved as recruitment occurred over a suitable time period, with low rates of attrition and good protocol adherence achieved. Patients, family members and multi-disciplinary staff reported high levels of acceptability for each intervention arms. There were low rates of complications and failure within all the study arms with all- cause complication evident in 16% (n=5/32) in both the standard care and IDS groups and 13% (n=4/33) in TA group.
Conclusions: It is feasible to conduct an efficacy RCT or participate in large multi-site RCT to establish efficacy of the studied interventions. Further research is required to definitively identify clinical, cost-effective methods to prevent PICC failure by examining new dressing and securement technologies.
17. The challenges and opportunities in merging two paediatric hospitals: creating reliability in vascular access care.
Ms. Tricia Kleidon1-3, Ms. Rachel Edwards1, Ms. Janet Wallace1, Ms.Julieta Woosley1,2 Ms. Anna Dean1,2, Ms. Juliana Buys1, Mr. Michael Lewcuk1, Ms. Amanda Ullman2,3, Professor Claire Rickard,2,3
1 Lacy Cilento Children’s Hospital, CHQ HHS, South Brisbane, Queensland, Australia,
2 Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Griffith University, Kessels Rd, Nathan, QLD, Australia
3 NHMRC Centre of Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia.
Introduction: The Lady Cilento Children’s Hospital is a new Queensland paediatric tertiary hospital uniting the Royal Children’s Hospital, and the Mater Children’s Hospital; combining specialties previously unique to the former hospitals. Vascular access (VA) was ubiquitous to both hospitals and has continued at the new hospital. To ensure standardised, evidenced based practice across the new hospital facility the insertion and management of central venous access devices (CVAD) need comprehensive review and education.
Objectives:
1. To describe the processes, challenges and benefits of combining and standardising VA practices in a new hospital facility.
2. To outline the development of a collaborative partnership between multi-disciplinary clinicians to ensure standardised practice in VA
Methods: A case study analysis describing a recent project that examined current practices and rates of complication in VA and implemented a sustainable education and audit plan to ensure standardised best practice across the new hospital.
Results: The analysis identified challenges associated with (1) variation in staff VA practice, (2) clinical challenges due to the facility design and increase in single room patient accommodation, and (3) translating knowledge into practice across a large hospital utilising existing resources. Strategies for managing these challenges included (1) maintaining a CVAD database (2) standardising CVAD practices through a train the trainer approach (3) engaging local staff in the process, as ’CVAD heroes’ - championing best practice, auditing ongoing practice and providing peer feedback to support accountability in CVAD practices with the aim of increasing consistency.
Conclusions: Ensuring consistency in CVAD practices is challenging and requires a multi-modal approach. It is imperative that local champions are engages to ensure reliable, standardised practice with low rates of complication.
19. Peripheral arterial catheters: the knowledge to practice puzzle
Heather Reynolds BA BHlthSc MN MAP PhD
Introduction: Peripheral arterial catheters are vascular access devices which have extensive usage worldwide. Anaesthestists and intensive care clinicians routinely insert these catheters for continuous blood pressure monitoring and blood sampling for management of complex surgical and critically ill patients. There is a gross imbalance between the high global use of millions of arterial catheters annually, and the lack of quality research regarding their management.
Objectives: To provide evidence-based information on the evaluation of the latest research about the clinical management of peripheral arterial catheters to update on future research needs.
Method: An overview of peripheral arterial catheter evidence provided analysis of research approaches, topics and outcomes.
Results: The literature about peripheral arterial catheter care and management was categorised according to infectious and mechanical complications which led to catheter failure. Sepsis rates in high acuity patients showed an infective potential at least equal to short term central venous catheters.
Mechanical failure involved accidental removal, infiltration, phlebitis, occlusion, thrombosis and inadequate dressing/securement. Randomized controlled trials investigated infectious outcomes but rarely mechanical complications which were mostly studied using observational and cohort methodologies.
Conclusions: A considerable body of evidence about infectious complications has employed high quality randomized controlled trials, but lower quality evidence provided limited knowledge about the mechanical failure, in particular dressing and securement. The need for randomized controlled trials to test dressing and securement options in relation to catheter failure was identified as a much needed area for future research.
22. Implementing a hospital-wide care bundle to reduce staphylococcus aureus bloodstream infections associated with peripheral venous cannulation
Rhodes D, Bass P, Kennon J, McLellan S, Guerra P, Karanfilovska D, Aitchison S, Watson K, Cheng AC, Worth LJ
Infection Prevention and Healthcare Epidemiology Unit, Department of Infectious Diseases, Alfred Health, Victoria, Australia 3181
Background: Healthcare-associated Staphylococcus aureus bacteraemia (HA-SAB) infections are frequently regarded as preventable and infection rates are reported as a national hospital performance indicator. The objective of this study was to implement a hospital-wide quality improvement program for optimal peripheral intravenous catheter (PIVC) care to reduce the incidence of HA-SAB.
Methods: Baseline clinical practice and SAB rates were evaluated for a 12 month pre-intervention period. A multi-faceted intervention was implemented: heightened awareness of infection risk, use of a phlebitis assessment tool, improved documentation, alerts and standardised equipment. SAB rates and repeat clinical auditing were evaluated for a 12-month post-intervention period. The nationally- agreed surveillance definition for HA-SAB was applied. PIVC-associated HA-SAB was defined as bacteraemia while a PIVC was in situ or within 48 hours of PIVC removal if no other primary site of infection was present.
Results: An increased frequency of phlebitis scoring and improved documentation was observed post- intervention. Fewer PIVCs were left in situ for ≥4 days during the post-intervention period (2.6 vs. 6.9%, p<0.05). During the pre-intervention period a HA-SAB rate of 1.1/10,000 occupied bed-days (OBDs) was observed and 16/40 (40%) events were PIVC-associated. In the post-intervention period, a rate of 0.88/10,000 OBDs was observed and 6/32 (18.8%) events were PIVC-associated, representing a significant reduction in PIVC-associated events (p=0.035).
Conclusions: A hospital-wide multi-faceted intervention to improve PIVC insertion and management practice successfully reduced PIVC-associated SAB events. Required resources were less than projected costs of prevented infections, confirming a favourable cost-benefit ratio.
23. The use of extended dwell pivcs in patients with difficult access
Evan Alexandrou
Senior Lecturer and Clinical Nurse Consultant, Liverpool Hospital, NSW Australia.
Introduction: Over a third of patients that present to hospital requiring a PIVC are reported to have difficult venous access, therefore, requiring multiple attempts to gain access. Multiple failed attempts to gain access can result in slightly discomfort to severe pain, delay in the commencement of treatment as well as increased risks of phlebitis, thrombosis and catheter related infection – all of which lead to premature device failure. The use of extended dwell PIVCs using ultrasound guidance can provide an alternative approach to central venous cannulation for patients with difficult access. Extended dwell PIVCs can be inserted in the upper peripheral veins and removed when clinically indicated, therefore reducing multiple cannulation attempts.
Objectives: Describe the use of extended dwell PIVCs for patients with difficult venous access in a large tertiary referral hospital in Sydney Australia.
Methods: Patients referred to the hospital central line service for difficult access underwent a vascular assessment for suitability for an extended dwell device. Patients with vessel depth of 1cm or less from the skin received a 4.8cm extended cannula (BD Nexiva) and those with a greater depth received a 10cm catheter (Bard Powerglide). All patients were followed routinely to ascertain reason for removal and for any clinical symptoms of phlebitis of thrombosis.
Results: Over 80 devices have been placed since September 2015. The majority of patients required cannulation for IV antibiotics. The average dwell to date has been 9 days (range 2 days to 28 days) for the 10cm catheter and 5 days (range 1 day to 16 days) for the 4.8cm cannula. To date there have been no episodes of symptomatic phlebitis or thrombosis for either device. Devices that prematurely failed were due to occlusion, dislodgement and infiltration.
Conclusion: This single centre experience has shown promising results for the use of extended dwell PIVCs in patients with difficult venous access.
24. A real time comparison of PICC tip positioning using fluoroscopy and an ECG tip confirmation and navigation system (TCS) to eliminate the need for chest x-ray post insertion
RN Kerry Taliaferro, RN Samantha Frost, RN Louise Turner, RN Katherine Wakefield, Canberra Hospital, ACT, Australia
Introduction: ECG tip navigation and confirmation systems have been established as a safe and effective alternative to fluoroscopy and Chest X-ray to determine PICC tip placement at the cavoatrial junction (CAJ). ECG TCS placement is reliant on observable P wave changes in the patients’ intravascular ECG trace. Ceasing CXR in this patient population removes a costly and time consuming component to tip verification.
Objective: To compare the real time position of a PICC tip during insertion using ECG TCS in conjunction with Fluoroscopy to ensure the safety of ceasing CXR post placement.
Method: Suitable patients requiring a PICC were selected to undergo insertion in the Interventional suite with both fluoroscopy images and an ECG trace stored at predetermined positions. Patient selection included adults with the ability to follow instructions and the presence of a consistent P wave on ECG.
ECG capture and fluoroscopy images were both taken on tip entry to the subclavian vein, the proximal, medial and distal SVC, Right Atrium and final tip position at the CAJ. Images were taken on both inspiration and expiration.
Result: At each stage the ECG TCS and fluoroscopy demonstrated agreement in tip position. Changes to the Hospital policy allowed credentialed inserters to release lines for immediate use in patients with observable P wave changes. This reduces time and resources spent on transport and decreases unnecessary X-ray exposure.
Conclusion: ECG TCS in patients with observable P wave changes can safely replace CXR in determining PICC tip location, releasing PICC lines for immediate use.
25. One million global catheters: peripheral intravenous cannula worldwide prevalence study (OMG PIVC study) in the east coast of peninsula Malaysian hospital.
Azlina Daud, International Islamic University Malaysia, Pahang, Malaysia
Introduction: There are over half of patients admitted to the hospital required peripheral intravascular cannula (PIVC) inserted. However, there is no data reported on the use of PIVC in Malaysia.
Objectives: To determine the prevalence of PIVCs use and PIVC complications in patients with PIVC.
Methods: An observational study was conducted on patients who had PIVC in medical, surgical, obstetric and orthopedic ward in Hospital Tunku Ampuan Afzan, Kuantan, Malaysia.
Results: Over 2 months, the total admission for 4 wards was 1466 and out of this total admission, 490 patients were recruited. Reasons for PIVC insertion were for IV fluids (62.6%) and for medication administration (33.6%). Most of the PIVC inserted in the general ward (96.5%) followed by from emergency department. The PIVC insertion was done by the doctor (96.7%). All patients used same brand of cannula which is Vasofix Branulle and used transparent polyurethane dressing. There was 15 (3.8%) patients have sign of thrombophlebitis.
Conclusions: In conclusion, the study processes resulted in a small proportion (33.4%) of patients with PIVC with the total number of admission to the 4 wards and 3.8% patients have sign of thrombophlebitis.
Keywords: Peripheral intravascular cannula, complications, thrombophlebitis
26. Randomised controlled trials in peripheral vascular access catheters: a scoping review
Ms Mari Takashima, Dr Gillian Ray-Barruel, Dr Samantha Keogh, and Prof Claire M. Rickard
Alliance for Vascular Access Teaching and Research (AVATAR) group, NHMRC Centre of Research Excellence in Nursing (NCREN), Centre for Health Practice Innovation, Menzies Health Institute Queensland, Griffith University, Nathan, Queensland, Australia
Introduction: Most patients require at least one peripheral vascular device during their hospital stay. Despite available best practice guidelines, the rate of complications and failure of these devices remains high, suggesting that more research is needed.
Objectives: We conducted a scoping review to identify which peripheral vascular device topics have been the focus of research, and to identify areas needing more research.
Methods: We searched Pubmed, Cochrane Central Register of Controlled Trials, and CINAHL between 1 January 2005 and 30 June 2015 for randomised controlled trials involving peripheral vascular catheters.
Results: The final review included 128 randomised controlled trials (94 peripheral intravenous catheters, 2 midline catheters, and 32 arterial catheters). Catheter insertion strategies and analgesia methods have been comprehensively studied. However, we found a lack of research addressing post-insertion care and maintenance, including dressings and securement, flushing practices and infection prevention strategies, such as skin preparation and hub decontamination.
Conclusions: There is insufficient evidence to guide practice in many areas of peripheral vascular device care. This is likely to be contributing to the high catheter failure rates reported in the literature. More randomised controlled trials investigating strategies for reducing catheter failure and preventing infection are needed. This scoping review will enable clinicians and researchers to identify the gaps in evidence and prioritise areas needing further research.
27. An evidence based rationale for nurse led central venous catheter placement
Evan Alexandrou, Senior Lecturer and Clinical Nurse Consultant, Liverpool Hospital, NSW Australia.
Introduction: Traditionally the insertion of a central venous catheter has been the doctor’s domain. With increasing specialisation and competing work demands for many trainee doctors, as well as the lack of procedural exposure to central venous catheter insertion, the safe insertion of such catheters by trainee doctors can pose significant procedural risks to patients including arterial puncture and pneumothorax. Several studies have identified clinician procedural volume as an important predictor of reduced adverse events. Similarly, increased experience with CVC placement has shown to improve both catheter- and patient-related outcomes.
Objectives: Describe the evidence for nurse led central venous catheter insertion.
Methods: A doctoral thesis. Two integrative reviews related to nurses inserting central venous catheters and three primary studies related to procedural and infection outcomes of nurses placing such devices.
Results: Nurse led central venous catheter placement improved organisational efficiency by reducing waiting periods for catheter placement as well as improving patient safety, including reducing infections. In one study, infection rates were 0.4/1000 catheters that were inserted by nurses compared to 2.5/1000 catheters inserted by medical staff. Similarly in another study the infection rate was 1.3/1000 catheters inserted by nurses compared to 7.2/1000 catheters inserted by medical staff. All primary studies conducted found no difference in procedural outcomes. In particular, a large study of 4560 catheters placed by nurses in a large teaching hospital reported a pneumothorax rate of 0.4% and overall infection rate was 0.2 per 1000 catheter days.
Conclusion: The series of studies presented provide the rationale for the benefits of nurse-led central venous catheter placement, where good training and supervision, along with providing dedicated individuals with significant procedural experience, can have great impact on patient outcome.
32. Application of failure mode and effect analysis model to reduce the incidence of venous indwelling needle.
Xuexue Li, Dahua Lan, Xi Zhang, Yingshuang Wang, Huan Deng, Jie Xiang, Shuang He
Corresponding author: Dahua Lan
Department of Haematology, Xinqiao Hospital, Third Military Medical University, ChongQing 400037, China.
Tel.: +86 023 68774325
Fax: +86 023 68763198
Email address: dahualan@hotmail.com
Abstract
Objective: To explore the effect of the application of failure mode and effect analysis (FMEA) to reduce the incidence of venous indwelling needle.
Methods: By draw method: 100 cases of patients who were treated in the Department of Haematology rehabilitation ward of our hospital from January 2015 to September 2015 and needed with venous indwelling needle, were chosen as object of observation, were divided randomly into observation group and control group, with 50 cases in each group. Observation group applied with FMEA in treatment, and the control group were treated with traditional method of retaining .They were evaluated by catheter blockage, extravasation, accidental pull off / off tube, puncture point infection, indwelling days.
Results: Observation group patients with catheter blockage, extravasation, accidental needle removal / de tube incidence was significantly lower than that of the control group, group differences are significant, with statistical significance (P < 0.05); group of patients with infection of the puncture point was observed in the PRN values and indwelling duration was significantly better than the control group, the group differences of ratio was statistically significant (P < 0.05).
Conclusion: FMEA risk manage mode is advantageous to reduce the incidence of catheter prolapsed, ensure transfusion safety, reduce complications, prolong indwelling time. It is worthy of promotion in the Department of Haematology rehabilitation ward.
Key words: medical failure mode; effect analysis; venous indwelling needle; removal rate
POSTERS
P1. Cessation of routine cxr following ecg guided picc placement – a lesson in changing minds and changing practice
Author: Ms Fiona Gillanders
Institution: St George Hospital, NSW, Australia
With the objective of ceasing routine chest x-ray (CXR) for confirmation of peripherally inserted central catheter (PICC) tip placement, the cancer services nurse PICC insertion team introduced an electrocardiograph (ECG) tracking confirmation system. Cessation of routine CXR following ECG guided PICC placement has proven patient, cost, time and resource benefits, however overcoming fear of the unknown can be challenging.
Over 12 months whilst the PICC team developed their own confidence and expertise of the system, they informed, educated and discussed the new technology with key stakeholders across the hospital, seeking endorsement and approval for a change in clinical and nursing scope of practice.
Key actions:
• Approval from line manager
• Arrange use of device, clinical training and ongoing support
• Engage lead cardiologist – request review of literature, endorsement of device
• Presentation to local products committee – gain consent for trial
• Record trial outcomes
• Engage radiology department – offer literature for review, oral presentation, suggest dual insertion if possible
• Prepare presentation – align literature, trial outcomes, and practice change benefits with the Australian Nursing and Midwifery Board Nursing Practice Decision Flowchart
• Draft amendment for local policy/procedure document
• Present to local leaders, key stakeholders and clinical groups – seek endorsement for change in policy
• Submit endorsed policy amendment to local policy governance group.
The PICC team learned valuable lessons in designing and following a systematic process to gain buy-in that leads to policy and practice change. We believe sharing our experience may help others succeed as we have thus improve the patient journey and reduce health spending.
P3. What is the frequency of thrombosis as a complication
of single and dual lumen piccs?
A retrospective audit.
Dr Mary Batch, Clinical Nurse 6C Wattlebrae, RBWH. Peter Groom, Nurse Unit Manager 6C Wattlebrae, RBWH. Prue Anderson, Clinical Nurse 6C Wattlebrae, RBWH. Geoff McQueen, Nurse Unit Manager Allamanda Private Hospital, Gold Coast. Dr A. Allworth, Director 6C Wattlebrae, RBWH.
Abstract
The use of peripherally inserted central catheters (PICC)s has increasingly become mainstream practice within the healthcare setting for the intravenous delivery of substances vital for patient care. Aside from the many benefits of these devices a serious complication is thrombosis with lethal outcomes. A retrospective audit to measure the frequency of thrombosis was carried out on all 4fr single or 5fr dual lumen silicon PICCs inserted during 2005-2009 in the Richard Kemp Day Therapy Unit, and removed whilst the patient was an in-patient. Of the 4fr single lumen PICCs inserted 6.7% were complicated by thrombosis compared to 10 % of 5fr dual lumen PICCs. Patients receiving chemotherapy with dual lumen PICCs represented a significant number of the patients who developed thrombosis.
P4. Removing the blindfold: has fluoroscopy guidance influenced thrombosis rates?
Mrs Tanya Clark, Ms Rhonda Wright, Ms Sheila Sams, Ms Kathrynne McKaskill, Dr Elisabeth Coyne
Gold Coast University Hospital & Griffith University, Queensland, Australia
Introduction: Peripherally inserted central catheter [PICC] related thrombosis is well documented, ranging from 1 - 40% depending on clinical management and assessment. There are a range of contributing factors which include vein to catheter ratio, patient disease processes, thrombosis history, site placement and PICC tip position. PICC tip position proximal to the lower third of the superior Vena Cava (SVC) has been shown to increase the risk of thrombosis. PICC insertion under fluoroscopy enables clinicians to visualise the tip during real time X-ray for optimal positioning. The Gold Coast University Hospital [GCUH] has a nurse led PICC insertion and management team [PICC Chicks] which has begun a new practice of fluoroscopy guided PICC insertion.
Objectives: This poster will present the adult thrombosis rates by fluoroscopic guided PICC tip positioning and recommendations for clinical practice.
Method: The GCUH PICC Chicks have maintained a database of PICC insertions and management over ten years, information includes demographics, PICC size, site, clinical information and complications. Thrombosis rates have been collected and collated yearly from 2010 to 2015.
Results: Thrombosis rates from the years preceding fluoroscopy ranged from 0.3% - 3.5%. Currently thrombosis rates remain below this at 1.8% with the new practice of PICC insertion with fluoroscopy.
Conclusion: The decrease in PICC related thrombosis rates since moving to fluoroscopic PICC tip positioning to the Cavo-atrial junction provides evidence to support this practice, however due to the multiple contributing factors for thrombosis it is difficult to establish that this is the sole reason for this reduction.
P5. Barriers to conducting clinical research on central venous access devices in the tertiary hospital setting
Melissa Arneil, Alexandra McCarthy, Nicole Gavin and Claire Rickard
Introduction: Conducting central venous access device (CVAD) research in the hospital setting provokes a number of challenges, due in part to the disruption of practice. During recruitment of a multisite randomised control trial (RCT) which compares 4-day versus 7-day intravenous administration set replacement, a multitude of barriers were identified. This provided the research team with invaluable knowledge about the challenges of conducting research on CVADs.
Objectives: To outline barriers encountered in this trial and strategies implemented to improve recruitment, data collection and trial compliance.
Methods: This case study describes the valuable knowledge gained by the research team. Challenges included:
1) recruitment; 2) engagement of clinicians; 3) integrating the trial with standard clinical practice.
Results: Strategies implemented to address issues included proficient use of systems to independently perform hospital wide screening of CVAD insertions. This improved the enrolment process and resulted in minimal disruption to workflow.
Clinicians and key stakeholders were engaged through in-services to gain understanding of current practice and create interest in the trial. Working alongside nurses in the clinical area enhanced the relationship between parties, promoting high trial compliance.
Successful implementation was maintained with a highly visible and flexible presence. Knowledge of the clinical environment and chemotherapy protocols, ensured recruitment of appropriate patients and improved integration with standard practice.
Conclusion: Conducting clinical research can be challenging. This is improved if the research nurse has a tool box of skills to work successfully alongside clinicians. The knowledge gained during this trial will be transferrable to CVAD trials in the future.
P6. Collaborative review of evidence-based guidelines in central venous access devices management
Danielle Peterman1,2, Lisa King1, Doctor Raymond Chan2,3,4,5,7, Nicole Gavin2,6,7, Sandy McKiernan2,8, Kerrie Curtis2,9, Rachel Edwards10, Rosita Van Kuilenburg11, Professor Claire Rickard6, Fiona Fullerton12
1. Cancer Institute NSW, NSW, Australia
2. Cancer Nurses Society of Australia
3. West Moreton Hospital and Health Service, Queensland, Australia
4. Centre for Health Practice Innovation, Griffith University, Queensland, Australia
5. Institute of Health and Biomedical Innovation, Queensland University of Technology, Queensland, Australia
6. NHMRC Centre of Research Excellence in Nursing Interventions, Griffith University, Queensland, Australia
7. Cancer Care Services, Royal Brisbane and Womens Hospital, Queensland, Australia
8. Cancer Council Western Australia, Western Australia, Australia
9. Day Oncology Olivia Newton John Cancer and Wellness Centre, Austin Health, Victoria, Australia
10. Queensland Childrens Cancer Centre, Lady Cilento Childrens Hospital, Queensland, Australia
11. Division of Cancer Services, Princess Alexandra Hospital, Queensland, Australia
12. Infection Management Services, Princess Alexandra Hospital, Queensland, Australia
Introduction: The majority of cancer nurses manage central venous access devices (CVADs) on a daily basis. While a number of clinical guidelines are available, clinicians are often uncertain of their quality and relevance to cancer care. The Cancer Nurses’ Society of Australia (CNSA) and eviQ Standard Cancer Treatments Online endeavor to direct cancer nurses to easily accessible and relevant evidence based clinical guidelines for CVAD management.
Aim: To develop a reference tool that outlines the quality of existing clinical guidelines for CVAD management and their relevance to cancer care.
Methods: This is a collaborative initiative of CNSA and eviQ. The review group consisted of nurse researchers, infection control experts, CVAD specialist nurses, paediatric cancer nurses and eviQ content authors. Thirty-four infection control and CVAD guidelines were identified through a systematic search and assessed for quality of the evidence and relevance, using a standardised assessment tool which evaluated the process of literature review, funding sources, plans for updating and the inclusion of the following clinical content: complications and trouble-shooting; dressings and securement; patient education; device selection; and accessing, flushing and locking. The reviewers independently assessed the guidelines and created recommendations to endorse, partially endorse or not endorsed by consensus.
Results: Four guidelines have been endorsed, seven have been partially endorsed and twenty-three have not been endorsed. A recommendation report will be published in early 2016.
Conclusion: This collaborative initiative will provide a reference tool that can guide clinicians to cancer specific, highest quality, evidence based guidelines for CVAD management.
P7. A time and motion study of peripheral venous catheter flushing practice using manually prepared and prefilled flush syringes.
Samantha J Keogh1,2, RN PhD; Nicole Marsh1,2, RN BN MAdvPract; Niall Higgins1,2, RN PhD; Karen Davies, RN PGDip2;
Claire M Rickard, RN PhD1,2
1. NHMRC Centre of Research Excellence in Nursing (NCREN), Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
2. Centre for Clinical Nursing, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
Introduction: Peripheral venous catheters (PVCs) are the simplest and most frequently used device in the hospital setting, however they are associated with inherent complications. There are a range of strategies to prevent or reduce complications that include the use of intermittent flushing. Objective: The aim of this study was to observe the nursing practice of flushing PVCs in a simulated ward setting (laboratory) when using two different flushing syringes.
Methods: The study used an observational time and motion design to gather data on preparation and use of manually prepared flushes compared to prefilled flush syringes. It also identified adherence to principles of ANTT and organisational protocol on PVC.
Results: Seven of the 12 nurses invited to participate in the study were available and agreed to participate. Each completed 10 scenarios: 5 manually prepared and 5 prefilled syringe flushes. A total of 70 scenarios were observed (35 in each arm). The mean total flushing time was 169 seconds for manually prepared flushes and 120 seconds for prefilled flushes, with a mean difference of 49 seconds (95% CI, 35-64, P > .001). All participants adhered broadly to the principles and steps of ANTT, with the exception of the use of personal protective equipment (PPE) and hub decontamination. In general, there was low awareness and a lack of adherence to the organisational protocol for administration of a PVC flush.
Conclusion: This observational study quantified preparation and administration time and identified deviation from aspects of ANTT and organisational protocol on PVC flushing when using manually prepared and prefilled syringes.
P8. Nursing and midwifery practice for maintenance of vascular access device patency.
A cross-sectional survey.
Samantha J Keogh1,2, RN PhD; Julie Flynn MAdvPrac BN, RN1,2, Nicole Marsh1,2, RN BN MAdvPract; Karen Davies, RN PGDip2;
Claire M Rickard, RN PhD1,2
1. NHMRC Centre of Research Excellence in Nursing (NCREN), Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
2. Centre for Clinical Nursing, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
Introduction: Up to 85% of hospital in-patients will require some form of intravascular therapy. Failure is high with 20 to 69% in peripheral intravenous catheters (PIVCs) and 15 to 66% of in Central Venous Catheters (CVC’s). Strategies developed to maintain vascular access device (VAD) patency, including flushing which may prevent occlusion. However current flushing practices of nurses and midwives are not well known.
Objective:The aim was to survey a large cohort of nurses and midwives to describe current VAD flushing practice.
Method: A cross-sectional survey of nurses and midwives working in the State of Queensland, Australia was conducted. A 25-item electronic survey was distributed. 1178 surveys were fully completed and analysed with n=1068 reporting PIVC flushing and n=584 reporting CVC flushing. The majority of respondents were aware of their facility’s policy for flushing. Most respondents used sodium chloride 0.9% for flushing both devices. Some concentration of heparin saline for flushing CVCs (25%). A 10mL syringe was used by most respondents for flushing PIVCs and CVCs. However 24% of respondents used smaller syringes in the PIVC group. The majority of respondents used manually prepared flush syringes. Frequency of flushing varied, with most common responses PRN (21-23%) or 6th hourly (23-22%). Approximately half of respondents stated no medical order or documentation for either PIVC or CVC device flushing.
Conclusions Flushing practice for VADs varies widely. Areas warranting further investigation include efficacy of heparin for CVC flushing, increasing adherence to use of 10mL diameter syringes, and improving documentation of flush orders and administration.
P9. Evaluation of different flushing frequencies and volume for peripheral intravenous catheters: a pilot, factorial randomized controlled trial.
Samantha Keogh PhD, RN1,2; Julie Flynn MAdvPrac BN, RN1,2; Nicole Marsh MAdvPract BN, RN1,2; Gabor Mihala MEng, GC Biostats1,3; Karen Davies BN, RN2; Claire Rickard PhD, RN1,2
1 NHMRC Centre for Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia.
1 Centre for Clinical Nursing, Royal Brisbane and Women’s Hospital, Herston, Australia.
3 School of Medicine, Menzies Health Institute Queensland, Griffith University, Meadowbrook, Australia.
Introduction: Peripheral intravenous catheters (PIVCs) are the simplest and most frequently used device in the hospital setting. There are a range of strategies to prevent or reduce complications that include intermittent flushing. However there are no large trials evaluating the effectiveness of various flushing regimens.
Objectives: To assess the impact of different flushing volumes and frequencies on PIVC failure.
Methods: This was a single centre, pilot, factorial randomised controlled trial. Participants included adult patients, with a PIVC expected to remain in-situ for ≥24 hours (n=160).
Patients were randomly allocated to one of four study groups: 10mL flush every 6 hours (HVHF); 10mL flush every 24 hours (HVLF); 3mL flush every 6 hours (LVHF), or 3mL flush every 24 hours (LVLF). The primary endpoint was PIVC failure, a composite measure of occlusion, infiltration, dislodgement, and phlebitis.
Results: PIVCs dwell time averaged 3.1 days (n=160). PIVC failure rates and survival across groups were not significantly different, (HVHF 8.1/1000 days; HVLF 6.8/1000 days; LVHF 6.5/1000 days, LVLF 3.6/1000 days, log-rank test p=0.06). Cox proportional regression to explore risk factors revealed that different flushing volumes and frequencies were not a predictor of failure. Multivariate analysis revealed that female gender (HR 2.2, p<0.01), hand/wrist insertion (1.7, p<0.05), and the episode rate (combined flushes and medication) (HR 1.2, p<0.01]) were significantly associated with PIVC failure.
Conclusion: The hazard of catheter failure is significantly predicted by female gender, hand/wrist insertion and episode rate. In that context, varied flushing volumes and frequencies alone did not significantly alter the risk of PIVC failure.
P12. Central venous access device dressing and securement: old habits vs evidence vs shiny new toys
AUTHORS: Amanda J Ullman1,2, Professor Claire M Rickard1,2, Professor Marie Cooke1,2
1 School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia,
2 Alliance for Vascular Access Teaching and Research (AVATAR) Group, NHMRC Centre of Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia,
Dependable central venous access devices (CVADs) are an essential component in the care of patients. Dressing and securement products are used to prevent CVAD failure and complication, but there are a large variety of products available for clinicians to access, with variable effectiveness.
Many decisions made by clinicians surrounding CVAD dressing and securement are based upon availability and tradition, rather than evidence.
The objective was to describe the effectiveness of CVAD securement and dressing products to prevent CVAD failure and complications. A Cochrane systematic review and a narrative review of CVAD securement and dressing products were undertaken and evidence from both studies synthesised.
Twenty-two randomized controlled trials were included within the Cochrane systematic review and 20 clinical and laboratory studies included in the narrative review. The major mechanisms CVAD dressing and securement products prevent failure and complications are through providing a barrier to microbial contamination and motion reduction. CVAD securement and dressing products provide these functions using coating, adhesion, antimicrobial properties, absorbency and moisture vapour transmission. Chlorhexidine-impregnated dressings are significantly more effective than plain dressings to reduce the incidence of catheter-related bloodstream infections (p=0.01) and catheter tip colonisation (p<0.001). Many novel solutions for CVAD securement are available to reduce the need for suturing, including tissue adhesive, sutureless securement devices and integrated securement and dressing products, but greater evidence surrounding effectiveness is necessary.
CVAD securement and dressing products provide important, multi-faceted functions to prevent CVAD failure and complication. The complexity of patients requiring CVAD means that universal recommendations and broad generalisation of studies’ results from single populations or devices are ill-advised.
P15. Outcomes of 35cm flexible femoral haemodialysis catheters in a tertiary centre
Dr. Matthew Devine 1
Dr. John Harper 1
1 Department of Radiology, Princess Alexandra Hospital, Brisbane, QLD, Australia
Temporary haemodialysis catheters are often inserted into the common femoral vein (CFV). However, there are concerns regarding potential complications including reduced mobility and deep venous thrombosis (DVT). It is uncertain whether use of longer flexible catheters affect these outcomes.
Since June 2012, 35cm non-tunnelled flexible silicon CFV catheters have been used at the Princess Alexandra Hospital. This retrospective study presents the outcomes from all insertions of this catheter type from June 2012 to October 2015, with the findings intended to optimise use of these devices.
Systematic review was undertaken of paper and electronic medical records. A total of 129 catheter insertions were performed, on subjects of mean age 57 (± 16) years. Most common indications for insertion were acute kidney injury (51%), arteriovenous fistula dysfunction (29%) and pre-existing catheter dysfunction (14%). Mean duration of catheter use was 5 (± 3) days. 90 cases (70%) were uncomplicated. The most common complication was bleeding from the insertion site (n = 16; 12%), typically resolving within 24 hours in non-coagulopathic patients. 13 catheters (10%) developed inadequate flow rates following initial normal function. Localised infection occurred in four cases, with only one instance of bacteraemia. Only one non-occlusive DVT was identified (<1%). In patients whom mobilisation was not contraindicated, 90% ambulated within 24 hours of catheter insertion.
These findings suggest that short-term use of 35cm flexible CFV haemodialysis catheters is associated with low risk of DVT, and allows prompt mobilisation in the majority of cases. However, increased catheter length may predispose to flow-related complications.
P18. Peripherally inserted central catheter outcomes polyurethane versus endexo: PICC compare randomised controlled trial feasibility study protocol
Ms. Tricia Kleidon1-3, Ms. Amanda Ullman2,3, Ms. Sarah Northfield2,4, Dr Li Zhang2,3 , Mr. Gabor Mihala2,3 Ms.Victoria Gibson1,2,
Dr.Brett Chaseling1, Dr.Jason Schoutrop,1 Ms. Julieta Woosley1,2, Ms. Anna Dean1,2, Professor Claire Rickard,2,3
1 Lady Cilento Children’s Hospital, CHQ HHS, South Brisbane, Queensland, Australia,
2 Alliance for Vascular Access Teaching and Research (AVATAR) Group, Menzies Health Institute Queensland, Griffith University, Kessels Rd, Nathan, QLD, Australia
3 NHMRC Centre of Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia.
4 Centre for Clinical Nursing, Royal Brisbane and Women’s Hospital, Butterfield Rd, Herston Qld
Introduction: Peripherally inserted central catheters (PICCs) provide short to medium term vascular access however they are associated with a high rate of mechanical and infectious complications. These complications may cause an interruption to necessary treatment, which can be life threatening. New technologies (BioFloTM) have been developed which makes it difficult for thrombosis (blood clots) and bacterial film to adhere to PICCs, but these have not been tested for effectiveness.
Objectives: Pilot test the feasibility of a randomized controlled trial (RCT) of the comparative efficacy and cost effectiveness of BioFlo™ PICC with older generation polyurethane PICC in the paediatric population; and examine the presence of biofilm formation on the internal and/or external lumens.
Methods: This is a multi-centre, parallel group, pragmatic pilot study to assess the feasibility of a definitive RCT comparing; the effectiveness of BioFlo™ PICC to older generation polyurethane PICC in tertiary paediatric and adult facilities. One hundred and ten participants will be recruited at both the Lady Cilento Children’s Hospital (LCCH) and the Royal Brisbane and Women’s Hospital (RBWH) over six months.
Data analysis: Randomised patients will analysed by intention to treat, irrespective of treatment. Descriptive statistics are used to describe the sample and to compare groups at baseline. Feasibility outcomes analysed by descriptive statistics including effect size estimates and 95% confidence intervals. A P value <0.05 is considered significant.
Conclusions: The current 30% PICC failure rate in a medically necessary device is unacceptable. Replacement of PICC due to complication and failure is costly. If new technology can prevent PICC failure outcomes for patients will be drastically improved. These results can significantly impact international health policies, decrease hospital budgets, reduce nursing/medical work and improve patient experiences.
P20. Development of a sustainable model for a nurse led intravenous access team (ivat) with the ability to cover planned leave within allocated funding
RN Kerry Taliaferro, RN Katherine Wakefield, Canberra Hospital, ACT, Australia
Introduction: In 2013 a project officer was recruited to develop a model for an Intravenous Access team for Canberra Hospital. While investigating existing Vascular Access Teams it was noted that in many models if the Vascular Access Nurse was on leave the service was not operational. To allow for a robust team, funding was sought for a team of three nurses, however was allocated for a permanent Clinical Nurse Consultant (CNC) and one RN Level 2 position.
Objectives: To provide a service with two credentialed inserters scheduled daily to enable the ability to cover planned leave, within the allocated funding.
Methods: A permanent CNC was appointed. To allow for growth in credentialed inserters an expression of interest for a fulltime RN 2 position for a six month rotation was advertised. A training and credentialing program utilising adult learning principles was developed for the secondment.
Successful candidates work closely with the CNC to develop PICC placement skills under Ultrasound guidance and ECG Tip navigation and confirmation. Following the six month placement RN’s return to their unit with advanced skills in CVAD management.
Results: Currently three RN’s have been trained in the program and are proficient in PICC insertions. To enable their continuing competence inserters return to the IVAT to cover planned days off and scheduled leave.
Conclusion: Canberra Hospital IVAT is able to provide leave cover for credentialed staff with competent PICC inserters within a limited funding model. As the service expands an additional permanent RN 2 position is anticipated.
P21. Development of a intravenous access team referral and booking form incorporating the national safety and quality health service standards
RN Kerry Taliaferro, Canberra Hospital, ACT, Australia
Introduction: In order to ensure a streamlined process for PICC insertion from referral to post insertion care, Canberra Hospital Intravenous Access Team developed a customized referral and booking form.
Objectives: To incorporate the National Safety and Quality Health Service Standards into a clinical form to ensure robust and complete patient preparation and documentation.
Methods: The form was designed to give clarity to the patients’ journey from initiation of the request to follow up care including:
Notification of patients requiring PICC line insertion
Reason for insertion, including type and length of intended therapy
Assessment and preparation of patient prior to insertion, including falls, pressure injury risk and potential clinical deterioation
Potential risk factors, including any issues with previous CVAD lines Ensuring education re PICC care is given to patient and carers
Ensuring process is followed regards clinical handover during the patient journey Obtaining written consent
Documentation of Time out and surgical asepsis
Tip position, length of line external and internal measures, release of the line for use Post procedure care outlined
Results: The form is well utilised by Canberra Hospital medical and nursing staff, with clear orders for insertion and patient preparation documented.
IVAT nurses are able to assess patients and proritise the days insertions based on organisational and patient needs.
Procedural care is documented, evidence avaiable that patient has been educated, surgical aseptic technique maintained, PICC line details and tip position are clearly documented.
Conclusion: PICC lines are inserted according to best practice and in line with National Standards.
P28. Quality improvement initiatives to reduce hospital acquired staph aureus- blood stream infection rates associated with peripheral vascular catheters in a large tertiary hospital in Western Australia
Ms Bobby Kemp, Clinical Nurse Consultant Intravascular Access, Sir Charles Gardiner Hospital, Western Australia, Australia.
Insertion of Peripheral Vascular Catheters (PVC) is the most commonly practised procedure in hospital settings, yet compliance with best practice at the time of insertion and maintenance post insertion remains a patient safety healthcare concern. Following a rise in PVC HA-Staph aureus BSI’s in our acute tertiary hospital during 2013, a number of quality improvement, patient safety initiatives were implemented. These initiatives involved a collaborative approach from all healthcare disciplines to challenge and improve present PVC practises, with the aim of reducing PVC HA-BSIs to zero. A Nurse Led Vascular Access Working Party was established in January 2014, comprising the Nurse Led IV Access Service, Infection Control Nurses, Consultant Microbiologist, Anaesthesia, ED, ICU and nursing staff including Clinical Nurse Specialists and Staff Development Nurses.
The working party participants have embraced the challenge of meeting the goal of zero PVC HA- BSI’s. To this end, a number of initiatives including trialling PVC insertion kits, reviewing guidelines, developing a Clinical Guideline for medical and nursing staff, roll out of the aseptic technique framework and scrub the hub, developing educational tools, surveillance audits and reviewing hospital IV trolley content were introduced. Feedback and support from the highest executive tier has enabled multi-disciplinary engagement.
From January to August 2015, the goal of zero PVC HA-BSI’s was achieved; however a rise in September/October 2015 highlights this issue as an ongoing challenge for all healthcare professionals. This poster will outline the quality improvement initiatives implemented, educational tools developed, surveillance audit results and ongoing progress towards this goal.
P29. A collaborative approach to reducing incidence of vascular air embolus and central venous access devices in New South Wales
Ms Margherita Murgo1, Ms Vicki Fox1, Ms Kaye Rolls2, Clinical Excellence Commission, NSW, Australia1 Agency of Clinical Innovation, NSW, Australia2
Vascular Air Embolism (VAE), a national sentinel event in certain circumstances, was reported regularly through the jurisdictional serious incident investigation process in NSW. Two patient safety notices had previously been issued to alert clinical staff to risks related to Central Venous Access Devices (CVAD) and VAE. Additional investigation through a clinical focus report was warranted after ongoing sentinel events, which were considered preventable. The Clinical Excellence Commission produces these reports to develop system wide recommendations with the intent of decreasing patient risk.
A word search of the incident management system was conducted using search terms related to VAE and CVAD. A clinical expert group was convened to develop the report and recommendations and a program of work was commenced to support practice change in NSW.
There were 14 VAEs recorded through the incident management system between 2012 and 2015 including 6 deaths. All events related to CVAD insertion, management or removal. 9 incidents were in critical care areas, 9 during removal with 7 related to semi-recumbent positioning. A number of system, human and patient factors were identified and 3 system and 6 point of care recommendations were made to reduce patient risk, including a request for product information from the industry.
Subsequently, an awareness raising campaign and standard education tool was delivered through collaboration between NSW pillar organisations to promote penetration to risk areas. Evaluation of this process to deliver safety messages is underway.
CVAD VAE is a serious preventable complication requiring a multifaceted approach to reduce patient risk.
P30. Intravenous lines – how well do we manage?
Karen Davies1 2, Yun Ying Tan2. Paul Kubler 1 Ian Coombes1 2, 1RBWH, 2UQ,
Introduction: There are around 5000 preventable intravenous device blood stream infections in Australia each year with a mortality rate of 24%. In 2013/ 2014 39% blood stream infections in a large teaching hospital in Brisbane were related to intravenous devices. This cost the organisation $900,000 in financial penalties alone.
Objectives: To determine the level of compliance with the hospital intravenous line procedure and identify possible reasons for non-compliance.
Methods: All adult general inpatient ward areas at a large teaching hospital in Brisbane were audited during August 2014, with the exception of Department of Intensive Care Medicine, Mental Health wards and Neonatal Intensive Care Unit. Patients with haemodialysis/apheresis catheters were excluded. Patients with intravenous access were identified by:- checking documentation, intravenous medications, intravenous fluid orders and asking the patient if they had an intravenous cannula insitu. The data was then collected using a pretested audit tool by sighting intravenous equipment, reviewing medication charts and patient interview. Nurses on duty were surveyed with a survey form handed out and collected on the day.
Results: OF the 226 patients with 895 intravenous lines 65% of lines were disconnected to administer medications with 51% not complying with hospital guidelines. 60% of intravenous line setups were not compliant, with 94% of nurses reasons stating it was because they were following hospital guidelines.
Conclusion: Education on the hospital intravenous procedure is required with emphasis on the importance of the potential risks of intravenous device blood stream infections associated with non-compliance.
P31. Improving peripheral intravenous cannula management: a large tertiary hospital perspective
Barbara Hewer, Tristan Bouckley, Jennifer Wu, Sarah Stewart, and Diane Murray.
Royal Brisbane and Women’s Hospital, Queensland, Australia
Introduction: Various factors contribute towards infection risk related to peripheral intravenous cannula (PIVC). An education strategy was devised to identify PIVC-related issues within the hospital and to educate staff, therefore improving PIVC outcomes. Objective: To increase compliance of PIVC management and documentation within the Royal Brisbane and Women’s Hospital. Method: PIVC’s within various inpatient wards of the hospital were surveyed by a dedicated vascular accessing training nursing team. Any issues identified with the cannula were immediately followed up through education to the patient’s direct team. Education included improving insertion site selection, assessing dressing and insertion site condition, correct PIVC equipment selection, and documentation adherence. A brief in-service was conducted once all included wards had been reviewed. The surveillance procedure was undertaken four times. Results: Between surveying periods, there was a significant reduction in the use of secondary dressings over the PIVC site (p <0.01). In addition, there was a 12.8% reduction in PIVC’s inserted in the antecubital fossa, from 79 of 291 (27.1%) in the first surveying periods, down to 21 of 147 (14.3%) within the second surveying periods (p < 0.01).
Conclusion: The immediate one-to-one education at the bedside for identified issues appears to have reduced insertions within the antecubital fossa and decreased the use of secondary dressings, both of which are linked to increased risk of acquiring a PIVC-related infection. The change of practice promoted more visible and clean sites, which studies indicate are less prone to complications.
P33. Saying ‘NO’ to routine cannula replacement
Abstract
Context and problem: In April 2014, an interdisciplinary group of vascular access preservation focused health care professionals led Capital Coast District Health Board (CCDHB) to be the first DHB in New Zealand (NZ) to implement a hospital wide non-specified dwell time for all peripheral intravenous cannulas (PIVCs). Routine replacement of cannulas has been a recommended standard of practice for decades, and with respect CCDHB had followed a 96-hour replacement frequency for adults.
Intervention and methodology: Recent studies have challenged replacement frequencies and created the opportunity to extend clinically indicated replacement to all populations. Clinically indicated cannula replacement has long been accepted among specific patient populations i.e. for infants, children and for difficult adults. Worries about phlebitis and bloodstream infection has prevented extension of this standard to all populations, yet the most common reasons for premature cannula failure are infiltration, occlusion and accidental removal. In response, cannula materials and systems have evolved dramatically, consequently reducing complications.
Phlebitis (the inflammation of a vein) can be a predictor of infection, which we measure using a visual tool commonly referred to as the phlebitis score. The tool identifies and combines observed signs and symptoms where the user decides a score out of 5, informing any intervention i.e. a phlebitis score >1 recommends prompt removal.
Measurement and results: Prior to implementation, our inpatient hospital population, currently observing the 96-hour replacement policy, was audited. Phlebitis scores were measured along with other indicators providing for baseline comparison.
One year on, our PIVC populations were re-measured and results verified the change was a success, with phlebitis rates >1 unchanged despite cannulas staying in place for longer.
Effects of change and adaptability to other settings: Implementing the PIVC replacement as clinically indicated only policy in CCDHB has been a safe and satisfying permanent change for our patients and health care professionals. Consideration should be given to implementing cannula replacement as clinically indicated only through other healthcare environments.